Eye and ear

What are the risk factors for dry ear syndrome?

Female gender

Older age

Postmenopausal estrogen therapy

certain meds

-antihistamines

-antidepressants

-diuretics

-beta blockers

-decongestants

-oral contraceptive pills

What are the exclusions for self treatment for ocular disorders?

eye pain

blurred vision not associated w/ophthalmic ointment

sensitivity to light

blunt trauma to eye

chemical exposure to eye

eye exposure to heat (excluding sun)

symptoms that have persisted for >72hrs

What are the treatment goals for dry eye syndrome?

alleviate and control dryness

relieve symptoms of irritation

prevent possible tissue or corneal damage

What are some non-pharm treatments for dry eye syndrome?

avoid dry/dusty places

use humidifiers

avoid prolonged use of computer screens

wear eye protection outdoors

eliminate offending medications

reposition work station away from air vents

Artificial tears

stabilize tear film

reduce tear evaporation

lubricate ocular surface

Non medicated ointments

increased retention time in eye

enhance tear film integrity

can cause blurred vision

Dry eye syndrome (mild discomfort)

artificial tears 1-2x/day

Dry eye syndrome (moderate discomfort)

artificial tears 3-4x/day

consider using gel formulation

Dry eye syndrome (severe discomfot)

preservative free artificial tears Q1H, if needed + ophthalmic ointment QHS

Dry eye syndrome (no improvement after a week)

refer to eye care provider

What are the steps to instill eye drops?

1) wash hands

2) tilt head back

3) grasp lower eyelid below lash line and pull away to make pouch

4) place dropper over eye by looking directly at it

5) before applying drop, look up

6) release eyelid after drop is applied

7) use finger to put pressure over opening of tear duct

8 ) wait 5 min before instilling next drop

What are the steps of instilling eye ointment?

1) wash hands throughly

2) tilt head back, grasp lower outer lid below lashes and pull down to form pocket

3) place ointment tube over eye, look up a

Instill solutions before suspensions

wait 5 min between drops

shake suspensions well before use

Instill drops before ointments

wait 10 mins between products

How does viscosity vary?

It varies based on vehicle and ingredients

As viscosity increases, contact time with the eye increases, chances for irritation and toxicity increases

What are the pros and cons of using preservative free?

Pros: useful for pts w/sensitives, use drops frequently w/compromised corneas

Cons: containers easily contaminated and more expensive

Disappearing preservatives

preservative rapidly dissociates into non-toxic compounds

limited preservative toxicity+antimicrobial activity

What are the signs and symptoms of allergic conjunctivitis?

red eyes

watery discharge

itchy, burning, or stinging sensation

What are some exclusions for self treatment of ocular disorders?

eye pain

blurred vision not associated w/ophthalmic ointment

sensitivity to light

history of contact lens wear

blunt trauma to eye

chemical exposure to eye

eye exposure to heat (excluding sun exposure)

symptoms that have persisted for >72hrs

Ophthalmic antihistamines/ mast cell stabilizer

potent histamine 1 receptor antagonist

inhibits mast cell degranulation—> stops release of inflammatory mediators

inhibits eosinophils—> stops release of late-phase mediators

Ketotifen fumarate (Zaditor) for allergic conjunctivitis

1 drop/eye BID (every 8-12 hrs)

can cause burning, stinging, and discomfort

can cause pupil dilation

contraindicated in people w/known risk for angle-closure glaucoma

APPROVED FOR USE IN >3yo

Olopatadine (Pataday)

Opthalmic antihistamine/mast cell stabilizer

1 drop/eye BID for 0.1%

1 drop/eye daily for 0.2%

Can cause burning, stinging, and discomfort

Can cause pupil dilation

contraindicated in people w/known risk for angle closure glaucoma

APPROVED FOR USE IN >2yo

Ophthalmic antihistamines

histamine receptor antagonist

Agents: pheniramine maleate and antazoline phosphate

1-2 drops 3-4 times/day

combination of ophthalmic antihistamine and decongestants is more effective than decongestant alone

What is the MOA of ophthalmic decongestants?

alpha adrenergic agonist→ constriction of conjunctival vessels→ reduced redness

What are some SE of ophthalmic decongestants?

can cause eye dryness

can cause rebound congestion, limit use to 72 hours

Naphazoline, tetrahydrozoline and brimonidine < oxymetazoline and phenylephrine

When should caution when using ophthalmic decongestants?

HTN

DM

CV and arteriosclerosis

hypothyroidism

Tetrahydrozoline (Visine) dosing

1-2 drops Q4H

Oxymetazoline dosing

1-2 drops q6h

Phenylephrine dosing

1-2 drops 4 times/day

Naphazoline (clear eyes) dosing

1-2 drops 4 times/day

Brimonidine (Lumify) dosing

1 drop q6-8H

What is the perferred choice for ophthalmic decongestants?

Naphazoline 0.02%

(Naphazoline, tetrahydrozoline, and brimonidine should be recommended before phenylephrine or oxymetazoline due to rebound congestion)

What ocular irrigants used for?

cleanse ocular tissue of unwanted debris while maintaining moisture (loosen foreign object)

specifically balanced pH and osmolarity

When should you not use ocular irrigants?

dont use if foreign object is wood or metal fragments

dont use on open wounds in or near eyes

When should your refer to PCP when using ocular irrigants?

continuous eye pain

changes in vision

continued redness or irritation

persistent or worsening condition

What is cornal Edema and its treatment goal?

halos or starbursts around lights

TG: draw fluid away from cornea

must be diagnosed by eye care provider before self treatment

How to treat Corneal Edema?

1st line: 2% NaCl solution 4 times/day

if sx persist 1-2 weeks: add 5% NaCl ointment QHS

if sx persist 1-2 weeks: switch to 5% NaCl solution + 5% NaCl ointment QHS

if sx persist 1-2 weeks: refer to eye care provider

What are some rec and CP for Ophthalmic disorders?

before counseling, consider nature and extent of ocular involvement

patients with acute ocular disease must have a prompt, definitive diagnosis

delay of definitive diagnosis and treatment can have serious complications→ severe visual impairment, blindness, scarring

some acute conditions can be appropriately treated w/OTC agents

What are some exclusions for self treatment of ocular disorders?

eye pain

blurred vision not associated w/ophthalmic ointment

sensitivity to light

history of contact lens wear

blunt trauma to eye

chemical exposure to eye

eye exposure to heat (excluding sun)

sx that have persisted for >72 hrs

What is the physiology of a child’s ear?

shorter, straighter, flatter ear canal

What is the physiology of an adult ear canal?

S SHAPED ear canal

Eustachian tube

lengthens downward

What is the purpose of ear wax?

Lubcricates ear canal

trap debris

waterproof barrier

antimicrobial properties

-contains lysozymes

-acidic pH

What are the signs and symptoms of impacted ear wax?

feeling of fullness/pressure

gradual hearing loss

dull pain

vertigo

tinnitus

chronic cough

What are the exclusions for self treatment of impacted ear wax?

signs of infection (irritation or rash)

pain associated with ear discharge

bleeding or signs of trauma

presence of ruptured tympanic membrane

ear surgery w/in 6 weeks

tympanostomy tubes present

incapable of following proper instructions

hypersensitivity to recommended agents

<12 yrs old

worsening conditions after attempted self-treatment

What are the treatment goals of impacted ear wax?

soften and remove earwax using safe, effective agents

proper treatments should eliminate temporary hearing loss

What is the general treatment approach for impacted earwax?

impacted ear wax should only be removed by trained pcp

caution warranted for patient attempts→ greater risk of EAC damage

active management of asymptomatic excessive cerumen is not required

What are some non-pharm treatments for impacted earwax?

ear wax should only be removed when in outermost portion of EAC

Curette- clean entrance to EAC only

warm water irrigation w/bulb syringe (do not use oral jet irrigator)

Products intended for insertion into ear canal→ cerumen impaction w/occlusion of ear canal, ruptured ear drum, or infection (use not rec by guidelines)

Carbamide peroxide 6.5% in anhydrous glycerin (Debrox)

MOA: hydrogen peroxide+ moisture= slows release of O2

-effervescent (makes bubbles)

Urea debrides tissue

glycerin softens earwax

Carbamide peroxide+irrigation is more effective than either alone (urea)

How to use an ear drop

1) wash hands throughly

2) warm ear drops to body temperature (hold in the palm of your hand)

3) if label indicates, shake the container

4) tilt head to the side or lie down with the affected ear up

5) position dropper tip NEAR the ear canal

6) pull ear backward and upward to open the ear canal

7) place the proper dose or number of drops into the ear canal opening

8 ) you may gently press the small, flat skin flap over the ear canal opening to force out air bubbles and push the drops down ear canal

9) stay in the x

What are the signs/sxs of water-clogged ears?

feeling of wetness/fullness

gradual hearing loss

ear exposed to excessive moisture

trapped moisture→itching, pain, inflammation, infection

earwax can absorb water and expand→trapping more water

swimmers ear is external otitis

What are the exclusions for self treatment for water clogged ears?

signs of infection

pain associated with ear discharge

dizziness

bleeding or signs of trauma

presence of ruptured tympanic membrane

ear surgery w/in 6 weeks

tympanostomy tubes present

incapable of following proper instructions

hypersensitivity to rec agents

worsening of condition after attempted self-treatment

What are the treatment goals of water clogged ears?

safely and effectively dry ear

prevent recurrences

What are some non-pharm treatments for water clogged ears?

tilt affected ear downward and manipulate auricle gently

blow dryer on low heat and speed (not directly into ear)

one time use water absorbing ear plugs

-remove after 10 mins

-for use by patients >16 yrs old

Isopropyl alcohol 95% in anhydrous glycerin 5%

only FDA-approved as ear drying aid

glycerin prevents over drying of ear canal

may sting or burn

-for water clogged ear treatment

1:1 mixture of acetic acid 5% and isopropyl alcohol 95%

do not use apple cider vinegar

may sting or burn